Early Prediction of Multi-Label Care Escalation Triggers in the Intensive Care Unit Using Electronic Health Records

Abstract

Intensive Care Unit (ICU) patients often present with complex, overlapping signs of physiological deterioration that require timely escalation of care. Traditional early warning systems, such as SOFA or MEWS, are limited by their focus on single outcomes and fail to capture the multi-dimensional nature of clinical decline. This study proposes a multi-label classification framework to predict Care Escalation Triggers (CETs), including respiratory failure, hemodynamic instability, renal compromise, and neurological deterioration, using the first 24 hours of ICU data. Using the MIMIC-IV database, CETs are defined through rule-based criteria applied to data from hours 24 to 72 (for example, oxygen saturation below 90, mean arterial pressure below 65 mmHg, creatinine increase greater than 0.3 mg/dL, or a drop in Glasgow Coma Scale score greater than 2). Features are extracted from the first 24 hours and include vital sign aggregates, laboratory values, and static demographics. We train and evaluate multiple classification models on a cohort of 85,242 ICU stays (80 percent training: 68,193; 20 percent testing: 17,049). Evaluation metrics include per-label precision, recall, F1-score, and Hamming loss. XGBoost, the best performing model, achieves F1-scores of 0.66 for respiratory, 0.72 for hemodynamic, 0.76 for renal, and 0.62 for neurologic deterioration, outperforming baseline models. Feature analysis shows that clinically relevant parameters such as respiratory rate, blood pressure, and creatinine are the most influential predictors, consistent with the clinical definitions of the CETs. The proposed framework demonstrates practical potential for early, interpretable clinical alerts without requiring complex time-series modeling or natural language processing.